For most of the COVID pandemic, North Korea has taken a different approach to the rest of the world. While other countries locked down and restricted international travel, the North Korean government took its own measures to protect itself, including denying the existence of the virus, refusing donations of vaccines and restricting information to its citizens.
In early 2020, North Korea had an advantage compared to other countries: much of the population never interacted with foreigners, as for most people international travel is tightly controlled and only rarely permitted. Even internal travel is heavily restricted, making it more difficult for a disease to spread.
Nonetheless the country was not completely isolated, because in the northern region many would illegally cross the border for occasional work in China and then return to North Korea. There was also a great deal of official traffic across the border. But in January 2020, the North Korean leadership completely closed the border and terminated almost all cross-border trade.
Fast forward to the beginning of 2022 and an outbreak of omicron in North Korea resulted in such a rapid spread of the virus that the strategy of COVID denial was no longer sustainable. Some sources have speculated that a massive military parade held to mark the 90th anniversary of the North Korean army was a super spreader event, resulting in a lockdown in the capital Pyongyang.
On May 20 the authorities stated that 2.5 million North Koreans had contracted COVID (referred to as the "fever"). Allegedly 1.8 million people have recovered and 66 people died. But it is highly likely that there has been much more illness and death.
North Koreans are particularly vulnerable for a variety of reasons. First of all, although the population is not obese (one factor in the mortality from COVID), many are suffering from severe chronic malnutrition. According to a UN report, 42.4% of North Koreans were malnourished during 2018-21. Moreover, the healthcare system is so underdeveloped that it cannot provide the life-saving treatments that many western COVID patients have received.
Andrei Lankov, the director of analysis and news company the Korean Risk Group, has reported that the North Korean authorities are advising the general population not to seek medical help but to treat the illness with paracetamol or ibuprofen. Lankov suggests that if they went to hospitals, the treatment they would receive would not be any different.
Previously in the pandemic
There was a risk early on that the virus would come to North Korea from China. Nevertheless, by April 2020 expert analysts believed that North Korea had largely succeeded in containing the outbreak.
Yet there were persistent reports of some COVID deaths. For example, it was reported early in the pandemic that 180 soldiers had died of COVID and 3,700 had been quarantined. However, establishing details of what is happening in North Korea is always extremely difficult because of secrecy and poor record keeping.
Extreme measures appear to have been taken both to prevent news getting out and to keep the virus under control. Sources say that doctors were not permitted to discuss COVID with anyone in order to protect the reputation of the country. The town of Kaesong, which is close to the South Korean border, was closed for a three-week lockdown because of just one case of COVID.
Until the end of 2021 the North Korean regime's approach to the outside world was one of denial. It claimed to be COVID free, relying on its total information control, as well as general authoritarian restrictions over the population. Although the outside world did not believe that North Korea was entirely free of cases, the leadership managed to maintain internal control.
However, this strategy of containment had severe consequences for the economy of North Korea as trade with China reduced to a trickle and the country, already under very severe sanctions from the United States, faced a severe and growing shortage of food.
The Kim Jong-un regime rejected foreign aid to help deal with the pandemic. In July 2021 North Korea was offered and rejected 2 million doses of the AstraZeneca vaccine. It also refused the 3 million doses of the Chinese vaccine Sinovac that were allocated to North Korea by the global vaccine team. Instead, Kim continued to deal with the pandemic in his own way.
For now, the greatest danger to Kim's authoritarian rule does not come from the general population, but from the country's elite. However, from the very beginning of the pandemic, the North Korean leadership has done its utmost to protect the elite, providing masks, requiring social distancing and privileged access to healthcare.
Elderly people in the remote countryside are most at risk. But the combination of increasing food scarcity, the economic consequences of domestic restrictions, the downturn in trade and the virtual collapse of informal markets due to the trade restrictions means that there are genuine risks to the stability of North Korea. Kim may be forced to accept more international help and reduce the burden of sanctions to control the situation.
This may explain the recent frequency of missile launches and preparations for a further nuclear test. As in the past, North Korea may seek to put pressure on the international community as a means to increase its bargaining power with the US.
It's not clear yet how the US will respond.
Author: Christoph Bluth - Professor of International Relations and Security, University of Bradford 
